Form CDC 57.400 CDC 57.400 Patient Safety Component---Annual Facility Survey for Am

Form Approved

OMB No. 0920-0666

Exp. Date: xx/xx/20xx

www.cdc.gov/nhsn

Patient Safety Component—Annual Facility Survey for Ambulatory Surgery Center (ASC)

Page 1 of 1

*required for saving

Tracking #:

*Facility ID:

*Survey Year:

Facility Characteristics

*Ownership (check all that apply):

□ For profit hospital

□ Not for profit hospital, including church

□ Government

□ Management company

□ Military

□ Veterans Affairs

□ Physician

□ Managed care organization

*Specialty (check one) :

☐ Multispecialty

☐ Single specialty

*Check all the specialty(ies) currently performed in your facility:

□ Bariatrics

□ Dental

□ General surgery

□ Gastroenterology

□ Gynecology

□ Neurology

□ Ophthalmology

□ Orthopedic

□ Otolaryngology

□ Pain management

□ Plastic surgery

□ Podiatry

□ Spine

□ Urology

□ Other (specify): _________________

*Total number of operating rooms at time of survey completion: _______

*Total number of procedure rooms at time of survey completion: _______

*Total number of patient admissions in this survey year: __________

*Accredited by a CMS-approved accrediting organization:

□ Yes

□ No

Assurance of Confidentiality: The information obtained in this surveillance system that would permit identification of any individual or institution is collected with a guarantee that it will be held in strict confidence, will be used only for the purposes stated, and will not otherwise be disclosed or released without the consent of the individual, or the institution in accordance with Sections 304, 306 and 308(d) of the Public Health Service Act (42 USC 242b, 242k, and 242m(d)). Public reporting burden of this collection of information is estimated to average 5 minutes per response, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. An agency may not conduct or sponsor, and a person is not required to respond to a collection of information unless it displays a currently valid OMB control number. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden to CDC, Reports Clearance Officer, 1600 Clifton Rd., MS D-74, Atlanta, GA 30333, ATTN: PRA (0920-0666). CDC 57.400, v8.5